Sasha Ayad, M. Ed., LPC

Pathologizing the Body: New Reflections on Mind-Body Incongruence

What role do our physical bodies play in our understanding of being? How does our embodied experience relate to the search for growth and meaning in life? Is there a true distinction between mind and body? These questions don’t have simple answers for any of us. For teens who are experiencing an incongruity between the physical body and their perception of self, the answers to these questions are even more obscure. It seems obvious in these cases that we, as therapists, helpers, and adults, should create guided opportunities for exploration, deeper insight, and ultimately, the ability to reconcile the real biological limitations of the physical body. Yet proponents of the “affirmative approach” believe our main role is to confirm the child’s dissociation and concretize it with medical alterations to the physical self, not to mention completely restructure gender as we know it. When weighing the two phenomena – the realities of the physical body and the imagination of the mind – we are asked to pathologize the former and take literally the latter. I propose that the body should not be the first target of our interventions, and that this is an unprecedented and dangerous way to approach children’s confusion.

One of the underlying assumptions of the affirmative approach is that “gender dysphoria” is an incongruence between biological sex and “gender identity”, which proponents claim, is innate and fixed throughout life. Advocates of this approach also believe that “gender dysphoria” is qualitatively so different from other forms of suffering, that it requires a radical and unprecedented type of remedy – medical and surgical modification to have the body imitate the opposite sex. For adults, this physical transformation is absolutely their right, if living in the opposite sex-role is something they carefully and freely chose to do. The idea that children can weigh, process, or consent to such drastic intervention, however, is completely unreasonable.

Additionally, having any body, being a conscious human being, and living in the world through the body, leads us all, inevitably, to broad and varied possibilities for unpleasantness or pain. Even people who have no psychiatrically diagnosable conditions experience a tremendous amount of suffering and discomfort at various points in their lives. Considering the sheer number of ways that our bodies can cause us to suffer (including conditions in which the mind is directly at odds with the body), is simply overwhelming. A flip through the DSM-5 or Merck Manual points to the myriad ways that something can “go wrong” in the either the body or mind. So how do we ethically and morally address these mind-body problems? Typically a least-invasive-first approach is standard, but in the world of gender ideology, politics and propaganda have managed to sweep that option right off the table.

To complicate matters, gender dysphoria is now being self-reported in unprecedented numbers, often by young teens who have declared themselves “gender dysphoric.” These self-diagnoses are sudden, and often manifest after the teen has read about the condition online. You’d think our first step is to examine how that initial exposure to the “wrong body” schema, combined with personal and individual vulnerabilities, might have lead her to believe she has the “wrong body.” Or, perhaps, we might begin by exploring what it means for a child, symbolically, to adopt a new identity and alienate herself from the body she has always inhabited. We mental health professionals are, instead, being instructed to bypass any case conceptualization or critical examination, and move right along to the next step: treatment. And specifically, one that addresses the body itself as culprit for the patient’s suffering, rather than perceptions of the mind. Rather than “saving lives” or exercising “compassion,” as proponents claim, this literal approach trivializes the gravity of the child’s experience of incongruence. It’s equivalent, in my view, to a doctor prescribing amputation for a patient who complains of arm pain. Or worse, complaining that they don’t “identify” with having an arm, and demanding an amputation – actually, this already happens.

Going back to my original question, why on earth do we regard other body-related mental health issues particular to adolescence as qualitatively different than the experience of gender confusion? I’ve asked myself this question over and over, and I’m certainly not alone. Many people have drawn comparisons between Body Dysmorphic Disorder, for example, and Gender Dysphoria. For every clearly-written, thoughtful critique of medically modifying dysphoric children, there are many more pieces alleging that gender dysphoria is significantly different and requires complete affirmation of what the patient’s mind is telling her.

Let’s look more closely at a few of these latter claims and their underlying assertions. In this article, the author, a transman named Austen Hartke, explains the differences between Body Dysmorphic Disorder (BDD) and Gender Dysphoria (GD), and argues that the former requires mental health treatment and the latter requires affirmation and medical transition – change the mind for one issue and change the body for the other.

BDD is characterized by persistent and intrusive preoccupations with imagined or actual, yet minimal, defects in one’s appearance and it usually develops in adolescents and teens around the ages of 12 or 13. A person with this condition erroneously magnifies the prominence of that “defect.” GD (even based on the confusing and vague definitions we currently have), is an incongruence between somebody’s biological sex, and what they believe their sex is or should have been. I avoid the phrase “identifies with” in defining GD because the term just means, “says it is so,” and is therefore meaningless for clarity of explication – has the person always claimed to be the opposite sex? Have they just recently taken on that identity? Does this sexed-body discomfort come only after learning about “transgender” identities? Our current understanding of GD doesn’t even attempt to answer these questions, but either way, a more useful framing defines the incongruence like this: the person’s belief about their sex is contrary to the material reality of their sex. In any case, let’s look at Hartke’s assertions:

BDD is about incongruence between perceptions and reality whereas GD is actually just a symptom and not a condition. Hartke writes,

Body Dysmorphic Disorder, or BDD, is a disorder in which your perception of your body does not align with reality. People with BDD are caught up in a cycle of obsessive thoughts about one or more parts of their body which they believe to be noticeably flawed–the word “dysmorphia” itself means “malformation.” Eating disorders fall under the BDD umbrella. Someone with an eating disorder, then, perceives a part or parts of their body to be overweight, and the obsession over that fact pushes them into a disordered relationship with food.

Transgender people, on the other hand, are diagnosed by the most recent Diagnostic and Statistical Manual of Mental Disorders (DSM V) with gender dysphoria. Gender dysphoria is not a disorder, and is now recognized not as a condition, but as a symptom. The word “dysphoria” means a sense of restlessness, anxiety, dissonance, or distress, and is the linguistic opposite of a sense of euphoria. Trans people experience this sense of distress when they contemplate the difference between the reality of their body, and the way they believe their body should be in order to align with their sense of self.

So, to sum up, body dysmorphia causes someone to believe their body is a certain way, while gender dysphoria is a sense that the body should be a different way. People with BDD are not able to see the difference between the way their body is and the way other people see their body; transgender folks are uncomfortably able to see the way their body really is, and the way that reality conflicts with their internal experience of their gender.

According to Hartke, we can’t draw a comparison between BDD and GD because the former involves an inaccurate perception of one’s body and an accurate perception of one’s body, while the latter revolves around an accurate perception of one’s body being different from what one believes it should be. This implies that reality isn’t objectively observable, nor is it based in the material realm at all. Furthermore, this magic rule only applies to people with GD! But a conviction that something is supposed to be different is actually quite similar to having an inaccurate perception of what is.

When it comes to the BDD sufferer, we acknowledge that their perception is flawed and treatable. For GD, it’s actual reality that’s flawed. Hartke (and others) makes the brain-melting claim that for a dysphoric person, inner beliefs trump physical, biological, and material realities, and that we must alter “reality” to match the psychological experience.

Why doesn’t he apply the same logic to sufferers of BDD? If a person sees her nose as being “too big”, for example, why isn’t that subjective perception given as much credence as someone’s “gender identity”? After all, it’s her strongly held conviction. Why is one type of inaccurate perception pathological while the other is a “symptom”? A symptom of what? Harke never explains this, but we’ll have to assume it’s a symptom of having the “wrong body”. The APA might say it’s a conflict between physical reality and the “true self.” In this self-referential vortex we find ourselves completely bereft of a rational or even useful explanation.

Hartke’s argument also implies that our fantasies, particularly – when they are incongruent with reality, have no nuance or symbolic value. What if a female client’s wish to be male is a subconscious attempt to find masculine energy and gain control over erratic aspects her life? What if a boy’s desire to be a girl is the manifestation of longing for intimate connections, belonging, or sisterhood? Perhaps affection is lacking in his too-macho male peer group at school. When a sudden shift in the “gender identity” of an autistic girl occurs right after seeing a “gender presentation” at school – could this actually reflect her tendency to think in absolutes about her own quirky interests and non-conforming gendered behavior? What if this young person is an effeminate gay man, or masculine lesbian woman, who sees no reflection of him/herself in the queer identity movement – or anywhere? Affirmative advocates would likely argue that those questions are “transphobic” and have no place in “supporting transgender children.”

Another important assertion made by Hartke relates to the differences in treatment for BDD and GD. He claims that the only way to cure dysphoria is to “affirm and transition” the child, and that talk therapy, by contrast is ineffective. Harke makes the opposite assertion when it comes to BDD, however, and claims that talk therapy is the best treatment for the condition. Hartke writes:

In the case of a mental disorder, psychotherapy and medication are generally shown to be helpful, and this is the case for body dysmorphia. People who suffer from eating disorders benefit greatly by cognitive and behavior therapy, and by the use of anti-anxiety and depression medications, including selective serotonin reuptake inhibitors (SSRIs). People dealing with gender dysphoria, on the other hand, do not experience relief from the sense of dissonance when put on medication, and though therapy is often helpful, it does not cause the dysphoria to subside….Gender dysphoria, on the other hand, effectively disappears once a trans person is allowed to physically transition.

Interestingly, Reid Vanderburgh is a therapist (once-lesbian, turned transman) who works with trans people who have increased dysphoria after transition. Contrary to the claims of “affirmative approach” advocates (and of Hartke), many dysphoric people experience even greater distress after being affirmed and transitioned. Vanderburgh reports that depression, despair, isolation, loneliness, and, in some cases, suicidality, are common among his patients post-transition. In another confounding paradox, in those cases, talk therapy is seen as helpful. Yet childhood-transition advocates implicitly warn that treating dysphoric kids with exploratory talk therapy (rather than straightforward affirmation) can lead to suicide. So, it’s considered appropriate to help people grapple with the limitations of their medical transformations, but not with the limitations of biological reality – I wonder which of these makes more money for the trans medical industrial complex…

In my practice, I’ve learned that the greatest psychological suffering often comes after one adopts a trans identity. This pattern in clients raises questions about the origin of dysphoria, particularly in Rapid Onset cases. Many members of the transgender community have affirmed my clinical findings on ROGD. You can read a strong consensus among commenters here and here.

Just as Vanderburgh has seen talk therapy as an effective treatment for dysphoric post-transition clients, I have also seen benefits of therapy for pre-transition clients. Trans-identified teens can and do experience a reduction, if not elimination, of gender dysphoria through talk therapy. Many of my clients have desisted in the context of support, respect, and careful exploration. Rather than take their feelings of incongruence at face value, we explore deeper messages signaled by their body-discomfort. Next time you hear that “desistance is a myth”, recognize the phrase as another misinformed and manipulative slogan used to pathologize (and medicalize) the bodies of trans-identified kids.

This raises another important question: is it ever appropriate to medicalize the body and alter it to fit with someone’s perceptions or to alleviate some emotional or psychological suffering? This deeply personal and moral question inspires me to share personal reflections on how it might feel to have the “wrong body”. When I was young, I never thought I should have been male after looking in the mirror, but I daydreamed about being a boy. Perhaps if I thought it was possible, I would have allowed my imagination to play more literally with that fantasy. I had, however, gone through a lifetime’s worth of medical problems by the time I was 30. When I experienced several near-fatal physical conditions and critical hospitalizations, nurses would be shocked at my medical charts and often tell me I was “too young” to be going through such extreme and unusual medical issues. In those moments, my body certainly didn’t feel “right”, but still, nothing like GD, I’d guess. But still, I couldn’t help but feel that something was terribly wrong, and perhaps I was supposed to have a “different body”. My experiences, eventually, resulted in recovery and a return to normalcy, and I deeply appreciate the fragility of our wellbeing. I started to think, recently, beyond those types of acute and manageable conditions. What about those of us whose body-wrongness, so to speak, never gets resolved – those with truly anomalistic or malfunctioning bodies? I wondered about young people with severe physical deformities which create vast barriers to social connection and typical teenage development. I imagine they have every right to blame the body for being “wrong” and to attribute their suffering to it’s irregularity.

In researching this question, I found some remarkably conscientious people sharing their experiences of having an unusual corporeal self:

These speakers are remarkable because they avoid becoming resentful about their bodies. Even though they had faced unscrupulous bullying and hatred for their looks, they didn’t make their appearance the central focus of their identity, or the central focus of their solutions. Each of these people had worked exceptionally hard to create meaning and purpose despite their physical limitations. They chose to seek connections with others, and find compassion for themselves. The growth processes of these individuals shows us that blaming the body for psychic and emotional pain is misguided. It isn’t that the body is absent in our formation of self, but, rather, that our life’s work is to learn how to relate (to self and others), precisely, through our embodied experience.

So when children are experiencing painful feelings of incongruence, are they simply rendered helpless to these mental misperceptions? Is it ethically sound that we should frantically and desperately reorder physical reality, catching their body to catch up with their thoughts?

No, of course not. Yet we are pummelled with that idea over and over, until we are too confused and too tired to think clearly.

Our go-to approaches must be those which are least disruptive and least risky. We must carefully study the impact of various types of psychotherapy on ROGD teens. We must remain scientifically grounded and morally watchful when dogmatic political agenda takes the place of ethical, compassionate care. The incoherent philosophy of “innate gender identity”, which underlies “affirmation” is not scientifically, psychologically, or philosophically sophisticated. At best it’s lazy and superficial, and at worst, it plays an iatrogenic function, creating pathology – and a life-long medical patient – out of thin air.

Comments

Very well written and I couldn’t agree more. I believe history will show that this particular craze and the role adults and mental health professionals have played to encourage/promote/support the medical experimentation on children will be viewed very harshly and begging the question, how could that have possibly happened. It’s unfathomable the pain and (lifetime) suffering a lot of these kids will be left to live with. Simply horrifying.

Hi Jay. Yes, I agree. If you look at the trajectory of Bulimia Nervosa and how it emerged and exploded, it has similar patterns. I’ve also seen comparisons to the iatrogenic phenomenon of childhood sexual abuse from the 90s. The danger we have here is a society which is not only widely reporting and discussing the issue, but completely celebrating it. It’s a bit of a moral dilemma. For those people (exceedingly rare) who have developed gender dysphoria as described in the medical/psychiatric literature, they should not have to bear stigma and discrimination. However, does explicit celebration and teaching “gender identity” theories to younger and younger school children play a role in the sudden adoption of a trans identity among teens? Of course, these are both important points to grapple with and sadly, no one is having that conversation. On the right, you have pundits yelling about it being a psychiatric condition (using a tone which indicates condemnation and ridicule) and on the far left people praising this as an identity to be celebrated. We’re never going to come to a good place for either transgender people or the kids falsely caught up in this vortex if we can’t have honest conversations about this.

Thank you for this incredibly articulate article. It sums up entirely my thinking on this whole isue and puts into words so much more eloquently than I could ever hope to. I’m completely at a loss as to why there is so much affirmation these days of being born in the wrong body. My guess is that as human beings we are susceptible to the power of suggestion and groupthink especially with the dawn of social media. Please keep up the good work. We need many more like you to challenge this harmful ideology.

I believe that part of the affirmation model is the false pretense that it’s the only approach that seriously deals with concerns about ethics, well-being, and outcomes for the teens in question. People can argue all day about whether “gender identity” is fixed and innate, but underneath that argument, I think people on the far left believe they are looking out for kids’ best interests and that gender critical people are dogmatic. I think it’s just another manifestation of how both ends of the spectrum have managed to take a moral high ground and demonize the other. This is happening with many issues in a parallel manner. Trans youth is only one outcropping of this phenomenon.

Thank you. I don’t dare tell certain folks that my daughter is going through GD right now and we’re not taking her to a gender therapist. Instead we have opted for traditional therapy and adhd/aspergers assessments, believing there is a root cause to this line of skewed body perception. Your article gave me hope.

This sounds like a good approach. I recommend thoroughly vetting any therapist before you start your child in any sort of treatment. I have written a piece about how to do that – if you are interested, you can either sign up for my newsletter (which will give you access to it) or email me and I can send you a copy.

This is absolutely true. Thanks for adding that point. Due to the nature of how people find my work and who contacts me, my interaction with families usually involves teen girls. Young adult females who are taking on a trans identity are not likely to contact me, and are more likely going directly to gender clinics for affirmative medicalized intervention.